Admission and Discharge Data Elements

_{Attachment A1 - TEDS admission and discharge data elements}

OMB No. 0930-xxxx

Expiration Date: xx/xx/xx

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  The OMB control number for this project is 0930-xxxx.  Public reporting burden for this collection of information is estimated to average 6.25 hours per respondent for admissions and 8.25 hours per respondent for discharges, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and assembling and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland, 20857.

TEDS Data Dictionary

System Data Set (SDS) Minimum Data Set (MDS) Supplemental Data Set (SuDS) Discharge Data Set (DIS)

TEDS DATA SYSTEM

This data dictionary contains detailed information about the data fields in the four data sets that make up the admission and discharge records of the Treatment Episode Data Set (TEDS). Information provided includes the field definitions, acceptable categories and coding structure, and guidelines for collecting and reporting the data to TEDS.

Each field has been assigned a reference number that incorporates the data set name and the position of the element in the State crosswalk. For example, the first element in the System Data Set is referred to as SDS 1.

Data Sets

The System Data Set (SDS) contains information needed to process the record. Both admission and discharge records include these elements.

The Minimum Data Set (MDS) contains information about the admission event. All States are required to report these fields.

The Supplemental Data Set (SuDS) also contains information about the admission event. States are encouraged to collect and report data for all categories in the list of valid categories. Collecting and reporting a subset of the categories is also acceptable. If the State collects only a subset of the categories, clients in all other categories must be coded as Not Collected.

The Discharge Data Set (DIS) contains information about the discharge event.

Key Fields

Certain fields are designated as key fields. Key fields are those elements which, taken together, uniquely identify each TEDS record. Key fields are common to both the admission and discharge record, and are used to link an admission record with its corresponding discharge record. A record with an invalid or missing Key Field is rejected and not added to the database.

Admission and Discharge Records

Admission records are comprised of the System Data Set, the Minimum Data Set, and the

Supplemental Data Set.

Discharge records are comprised of the System Data Set, the Discharge Data Set, and some fields from the Minimum Data Set.

Unknown, Uncollected, and Invalid Values

Three categories are collected for each data item

• Unknown The State collects these data but for some reason a particular record does not reflect an acceptable value.

• Not Collected The State does not collect these data for submission to TEDS.

• Invalid The value submitted was not a valid entry.

The following table summarizes the data sets, data elements, and record contents.

Admission Discharge

Data Set NOM Field Field

SYSTEM DATA SET System Transaction Type		SDS 1	DIS 1
State Code - Key Field		SDS 2	DIS 2
Reporting Date		SDS 3	DIS 3
MINIMUM DATA SET
Provider Identifier - Key Field		MDS 1	DIS 4, DIS 11
Client Identifier - Key Field		MDS 2	DIS 5, DIS 12
Co-Dependent/Collateral - Key Field		MDS 3	DIS 6, DIS 13
Client Transaction Type - Key Field		MDS 4	DIS 14
Date of Admission - Key Field Number of Prior Treatment Episodes Principal Source of Referral Date of Birth		MDS 5 MDS 6 MDS 7 MDS 8	DIS 15 DIS 17
Sex Race Ethnicity Education Employment Status	NOM	MDS 9 MDS 10 MDS 11 MDS 12 MDS 13	DIS 18 DIS 19 DIS 20 DIS 24
Substance Problem Code - Primary Substance Problem Code - Secondary Substance Problem Code - Tertiary Usual Route of Administration - Primary Usual Route of Administration - Secondary Usual Route of Administration - Tertiary	NOM NOM NOM	MDS 14 (a) MDS 14 (b) MDS 14 (c) MDS 15 (a) MDS 15 (b) MDS 15 (c)	DIS 21 (a) DIS 21 (b) DIS 21 (c)

Frequency of Use at Admission - Primary Frequency of Use at Admission - Secondary Frequency of Use at Admission - Tertiary	NOM NOM NOM	MDS 16 (a) MDS 16 (b) MDS 16 (c)	DIS 22 (a) DIS 22 (b) DIS 22 (c)
Age of First Use - Primary		MDS 17 (a)
Age of First Use - Secondary		MDS 17 (b)
Age of First Use - Tertiary		MDS 17 (c)
Type of Services - Key Field Medication-assisted Opioid Therapy		MDS 18 MDS 19	DIS 7, DIS 16
SUPPLEMENTAL DATA SET
Detailed Drug Code - Primary		SuDS 1
Detailed Drug Code - Secondary		SuDS 2
Detailed Drug Code - Tertiary		SuDS 3
DSM Diagnosis		SuDS 4
Psychiatric Problem in Addition to Alcohol or Drug Problem		SuDS 5
Pregnant at Time of Admission		SuDS 6
Veteran Status		SuDS 7
Living Arrangements	NOM	SuDS 8	DIS 23
Source of Income/Support		SuDS 9
Health Insurance		SuDS 10
Expected/Actual Primary Source of Payment		SuDS 11
Detailed Not-in-Labor-Force	NOM	SuDS 12	DIS 25
Detailed Criminal Justice Referral		SuDS 13
Marital Status		SuDS 14
Days Waiting to Enter Treatment		SuDS 15
Arrests in Prior 30 Days	NOM	SuDS 16	DIS 26
Frequency of Attendance at Self-Help Groups in Prior 30 Days	NOM	SuDS 17	DIS 27
DISCHARGE DATA SET
Date of Last Contact			DIS 8
Date of Discharge			DIS 9
Reason for Discharge			DIS 10

SYSTEM TRANSACTION TYPE SDS 1

DIS 1

Description: Designates whether the record is added to the TEDS database, changes an existing record in the database, or deletes an existing record in the database.

Valid entries: A Add

C Change

D Delete

An invalid entry in this field automatically sets the value of the field to “A.” Guidelines: Corrections and other changes to a record in the TEDS database can be accomplished

by Submitting A ”Change” (C) record or by submitting a delete (D) record along with an add (A) record to replace the deleted record.

STATE CODE – KEY FIELD SDS 2

DIS 2

Description: Identifies the State submitting the record. Valid entries: A valid two-letter State code.

If the field is blank, the record will not be processed.

REPORTING DATE SDS 3

DIS 3

Description: The date of the data submission to the contractor. Valid entries: MMYYYY

Identifies the month and year the records are submitted to the contractor. Every record in a State submission must contain the same date of submission.

PROVIDER IDENTIFIER – KEY FIELD MDS 1

DIS 4

DIS 11

Description: Identifies the provider of the alcohol or drug treatment service.

DIS 4 identifies the provider at time of discharge

DIS 11 identifies the provider at time of admission

Valid entries: Entry must contain a valid provider ID that matches the provider ID in SAMHSA’s Inventory of Substance Abuse Treatment Services (I-SATS). It may be a State PROVIDER ID as entered in the I-SATS, or the SAMHSA-assigned I-SATS Provider ID.

Any record with a TEDS Provider ID that does not match a Provider ID on the I-SATS will be processed and added to the database. In the TEDS data processing report, such records will be marked as “Provider not in I-SATS.” After consultation with the State, a list of these errors may be sent to the State so that correction to the TEDS or the I-SATS ID may be made.

If the field is blank, the record will not be processed.

Guidelines: The provider will usually be the same at both admission and at discharge, although the entry in DIS 4 (provider ID at discharge), but may be different. Even if the same, it must be entered in both fields DIS 4 and DIS 11.

CLIENT IDENTIFIER – KEY FIELD MDS 2

DIS 5

DIS 12

Description: A client is a person who meets all of the following criteria:

1. Has an alcohol or drug related problem, or is being treated as a co-dependent

(see instructions for MDS 3/DIS 6).

2. Has completed the screening and intake process.

3. Has been formally admitted for treatment or recovery service in an Alcohol or

Drug Treatment Unit

4. Has his or her own client record.

A person is not a client if he or she has only completed a screening or intake process or has been placed on a waiting list.

DIS 5 is the client identifier in use when the client was discharged

DIS 12 is the client identifier assigned at admission.

Valid entries: An identifier of from 1 to 15 alphanumeric characters that is unique within the State where possible and, at a minimum, unique within the provider.

If the field is blank, the record will not be processed.

Guidelines: The client identifier will usually be the same at both admission and at discharge (and should always be the same as at discharge when client ID is unique within the State), although the entry in DIS 5 (client ID at discharge), but may be different. Even if the same, it must be entered in both fields DIS 5 and DIS 12.

CO-DEPENDENT/COLLATERAL – KEY FIELD MDS 3

DIS 6

DIS 13

Description: A co-dependent/collateral is a person who has no alcohol or drug abuse problem, but satisfies all of the following conditions:

1. Is seeking services because of problems arising from his or her relationship with an alcohol or drug user.

2. Has been formally admitted for service to a treatment unit.

3. Has his or her own client record or has a record within a primary client record. States not collecting Co-Dependent/Collateral data default to 2 (No) for this field;

i.e., all records are substance abuse client records.

DIS 6 is the codependent/collateral status at discharge.

DIS 13 is to be obtained from linkage to the admission record.

Valid entries: 1 Yes

2 No

If the field contains an invalid value, the record will not be processed.

Guidelines: Reporting of data for co-dependent/collateral clients in TEDS is optional. If the State opts to report co-dependent/collateral clients, the mandatory fields are State Code, Provider Identifier, Client Identifier, Client Transaction Type, Co-Dependent/ Collateral, and Date of Admission. Reporting of the remaining fields in the MDS and the SuDS is optional for co-dependent/collateral records. For all items not reported, the data field should be coded with the appropriate “not collected” or “not applicable” code.

Other considerations:

If a substance abuse client with an existing record in TEDS becomes a co- dependent, a new client admission record should be submitted indicating that the client is an admission as a co-dependent. The reverse is also true for a person who is a co-dependent first and then becomes a substance abuse treatment client. For TEDS purposes, admission of such clients to substance abuse treatment would be submitted to TEDS as for any other treatment client.

CLIENT TRANSACTION TYPE – KEY FIELD MDS 4

DIS 14

Description: This field identifies whether a record is for an Admission (A) or a Transfer/change in service (T).

Valid entries: A Admission

T Transfer / Change in service

If this field contains an invalid value, the record will not be processed.

Guidelines: Admissions and transfers: For purposes of reporting to TEDS, a treatment episode is defined as that period of service between the beginning of treatment for a drug or alcohol problem and the termination of services for the prescribed treatment plan. The episode includes one admission (when services begin), and at least one discharge (when services end). Within a treatment episode, a client may transfer to a different service, facility, provider, program or location. When it is feasible for the State to identify transfers, they should be reported as “Transfers” in admissions data submissions. The TEDS transfer record includes the same data items as the Admission record, but with a Client Transaction Type of “T”. Each admission and transfer record should have an associated discharge record. When admissions and transfers cannot be differentiated in a State data system, such changes in service or facility should be reported to TEDS as admissions (A). An explanation of the reporting procedures should be noted in the State Crosswalk.

Data set considerations for transfers (T)

All fields from the transfer (T) record should be updated to reflect values at the time of transfer except the following fields, which must have the same values as in the associated (preceding) admission record:

• Client ID (MDS 2)

• Co-Dependent/Collateral (MDS 3)

• Date of Birth (MDS 8)

• Sex (MDS 9)

• Race (MDS 10)

• Ethnicity (MDS 11)

For transfer records:

• Date of Admission (MDS 5) is defined as the date services begin after the transfer to another service or facility.

All other fields should be updated when possible. If a field cannot be updated, it should be transmitted to TEDS with its value from the associated (preceding) admission record.

DATE OF ADMISSION – KEY FIELD MDS 5

DIS 15

Description: The day when the client receives his or her first direct treatment or recovery service.

For transfers, this is the day when client receives his or her first direct treatment after the transfer has occurred.

Valid entries: MMDDYYYY

If this field contains an invalid value, the record will not be processed.

MM must be 01 thru 12 and DD must be 01 thru 31. As of January 1, 2008, TEDS accepts records with a Date of Admission of January 1, 2002 or later. Each January thereafter, acceptable admission date will be one year later. Records with admission date prior to the acceptable date are rejected.

NUMBER OF PRIOR TREATMENT EPISODES MDS 6

Description: Indicates the number of previous treatment episodes the client has received in any drug or alcohol program. Changes in service for the same episode (transfers) should not be counted as separate prior episodes.

Valid entries: 0 0 previous episodes

1 1 previous episode

2 2 previous episodes

3 3 previous episodes

4 4 previous episodes

5 5 or more previous episodes

Guidelines: It is preferred that the number of prior treatments be a self-reported field collected at the time of client intake. However, this data item may be derived from the State data system, if the system has that capability, and episodes can be counted for at least several years.

The number of prior treatments for a co-dependent/collateral record should include only treatments as a co-dependent.

PRINCIPAL SOURCE OF REFERRAL MDS 7

Description: Describes the person or agency referring the client to the alcohol or drug abuse treatment program.

Valid entries:

01 Individual (includes self-referral)—Includes the client, a family member, friend or any other individual who would not be included in any of the following categories. Includes self-referral due to pending DWI/DUI.

02 Alcohol/Drug Abuse Care Provider—Any program, clinic or other health care provider whose principal objective is treating clients with substance abuse problems, or a program whose activities are related to alcohol or other drug abuse prevention, education or treatment.

03 Other Health Care Provider—A physician, psychiatrist or other licensed health care professional; or general hospital, psychiatric hospital, mental health program or nursing home.

04 School (Educational)—A school principal, counselor, or teacher; or a student assistance program (SAP), the school system, or an educational agency.

05 Employer/EAP—A supervisor or an employee counselor.

06 Other Community Referral—Community or religious organization or any federal, State or local agency that provides aid in the areas of poverty relief, unemployment, shelter or social welfare. Self-help groups such as Alcoholics Anonymous (AA), Al-Anon, and Narcotics Anonymous (NA) are also included in this category. Defense attorneys are included in this category.

07 Court/Criminal Justice Referral/DUI/DWI—Any police official, judge, prosecutor, probation officer or other person affiliated with a federal, State or county judicial system. Includes referral by a court for DWI/DUI, clients referred in lieu of or for deferred prosecution, or during pretrial release, or before or after official adjudication. Includes clients on pre-parole, pre-release, work or home furlough or TASC. Client need not be officially designated as “on parole.” Includes clients referred through civil commitment. Client referrals in this category are further defined in Detailed Criminal Justice Referral (SuDS

_13).

Other fields: SuDS 13 (Detailed Criminal Justice Referral) is used to provide a detailed breakdown of the “Court/Criminal Justice Referral/DUI/DWI” category (07). All records with category 07 designated as the source of referral should have an entry in data item SuDS 13 to further delineate the referral type.

DATE OF BIRTH MDS 8

DIS 17

Description: Client’s date of birth. Valid entries: MMDDYYYY

MM must be 01 - 12 and DD must be 01 - 31.

Other fields: This field is cross-checked with Item 17, Age of First Use (Primary, Secondary and

Tertiary) as follows:

If age, calculated as Date of Admission minus Date of Birth, is less than or equal to Age of First Use, Invalid will be entered in the date of birth field. The record will be processed and added to database.

SEX MDS 9

DIS 18

_{Description: Identifies client’s sex.}

Valid entries:	1	Male
	2	Female

Other fields: This field is checked against SuDS 6 – Pregnant at Time of Admission/Discharge.

RACE MDS 10

DIS 19

Description: Specifies the client’s race

_{Valid entries:}

01 Alaska Native (Aleut, Eskimo, Indian)—Origins in any of the original people of Alaska.

02 American Indian (other than Alaska Native)—Origins in any of the original people of North America and South America (including Central America) and who maintain cultural identification through tribal affiliation or community attachment.

13 Asian—Origins in any of the original people of the Far East, the Indian subcontinent, or Southeast Asia, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Philippine Islands, Thailand, and Vietnam.

23 Native Hawaiian or Other Pacific Islander—Origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

(States that cannot separate Asian from Native Hawaiian and other Pacific

Islander should use code 03)

03 Asian or Pacific Islander—Origins in any of the original people of the

Far East, the Indian subcontinent, Southeast Asia or the Pacific Islands.

04 Black or African American—Origins in any of the black racial groups of

Africa.

05 White—Origins in any of the original people of Europe, North Africa or the

Middle East.

20 Other single race—Use this category for instances in which the client is not classified in any category above or whose origin group, because of area custom, is regarded as a racial class distinct from the above categories. (Do not use this category for clients indicating multiple races)

21 Two or More Races—Use this code when the State data system allows multiple race selection and more than one race is indicated. (See guidelines below).

Guidelines: If State does not distinguish between American Indian and Alaska Native, code both as 02, American Indian.

States that can separate Asian and Native Hawaiian or Other Pacific Islander should use codes 13 and 23 for those categories. States that cannot make the separation should use the combined code 03 until the separation becomes possible. Once a State begins using codes 13 and 23, code 03 should no longer be used by that State. States are asked to convert to the new categories when possible.

Guidelines for States that collect multiple races:

A. When a single race is designated, that specific race code should be used.

B. If the state system collects a “primary” or “preferred” race along with additional races, the code for the primary/preferred race should be used, regardless of whether or not additional races have been designated.

C. If the state uses a system, such as an algorithm, to select a single race when multiple races have been selected for an individual, the same system may be used to designate the race code for TEDS.

D. When two or more races are designated and neither B nor C above apply, code

21 (Two or More Races) should be used.

ETHNICITY MDS 11

DIS 20

_{Description: Identifies client’s specific Hispanic Origin.}

Valid entries:

01 Puerto Rican—Of Puerto Rican origin regardless of race.

02 Mexican—Of Mexican origin regardless of race.

03 Cuban—Of Cuban origin regardless of race.

04 Other specific Hispanic—Of known Central or South American or any other Spanish cultural origin (including Spain), other than Puerto Rican, Mexican or Cuban, regardless of race.

05 Not of Hispanic Origin

_{06 Hispanic—Specific origin not specified—Of Hispanic Origin, but specific}

Guidelines: If a State does not collect specific Hispanic detail, code ethnicity for Hispanics as

06 Hispanic — specific origin not specified.

EDUCATION MDS 12

_{Description: Specifies the highest school grade (number of school years) the client has completed.}

Valid entries:

00 Less than one grade completed

01-25 years of school (highest grade) completed

_{(For General Equivalency Degree, use 12)}

Guidelines: States that use specific categories for designating education level should map their categories to a logical “number of years of school completed.” The mapping should be recorded in the State Crosswalk and programmed for production of the TEDS data. For example, a State category of “Associate Degree” should be mapped to TEDS years of school completed code 14; “Bachelor Degree” would be mapped to TEDS years of school completed code 16, etc.

EMPLOYMENT STATUS—NOM MDS 13

DIS 24

_{Description: Identifies the client’s employment status at the time of admission or transfer.}

Valid entries:

01 Full Time—Working 35 hours or more each week, including active duty members of the uniformed services.

02 Part Time—Working fewer than 35 hours each week.

03 Unemployed—Looking for work during the past 30 days or on layoff from a job.

04 Not in Labor Force—Not looking for work during the past 30 days or a student, homemaker, disabled, retired or an inmate of an institution. Clients in this category are further defined in SuDS 12-Detailed Not In Labor Force.

Guidelines: Seasonal workers are coded in this category based on their employment status at time of admission. For example, if they are employed full time at the time of admission, they are coded 01. If they are not in labor force at the time of admission, they are coded 04.

Other fields: SuDS 12 (Detailed Not in Labor force) is used to provide a detailed breakdown of the “Not in Labor Force” category (04). SuDS 12 should be coded as “96” (not applicable) when Employment Status is any code other than 04.

SUBSTANCE PROBLEM CODE

PRIMARY MDS 14 (A) & DIS 21 (A)

SECONDARY MDS 14 (B) & DIS 21 (B)

TERTIARY MDS 14 (C) & DIS 21 (C)

Description: This field identifies the client’s primary substance problem.

Each substance problem code (primary, secondary, or tertiary problem code) has associated fields for route of administration, frequency of use, age at first use, and (if collected) detailed drug code; e.g., Primary Substance Problem Code, Primary Route of Administration, Primary Age of First Use, and (if collected) Primary Detailed Drug Code.

Valid entries:

01 None

02 Alcohol

03 Cocaine/Crack

04 Marijuana/Hashish— Includes THC and any other cannabis sativa preparations..

05 Heroin

06 Non-Prescription Methadone

07 Other Opiates and Synthetics—Includes buprenorphine, codeine, hydrocodone, hydromorphone, meperidine, morphine, opium, oxycodone, pentazocine, propoxyphene, tramadol, and any other drug with morphine-like effects.

08 PCP—Phencyclidine

09 Other Hallucinogens—Includes LSD, DMT, STP, hallucinogens, mescaline, peyote, psilocybin, etc.

10 Methamphetamine

11 Other Amphetamines—Includes amphetamines, MDMA, phenmetrazine, “bath salts,” and other unspecified amines and related drugs.

12 Other Stimulants—Includes methylphenidate and any other stimulants.

13 Benzodiazepines—Includes alprazolam, chlordiazepoxide, clonazepam, clorazepate, diazepam, flunitrazepam, flurazepam, halazepam, lorazepam, oxazepam, prazepam, temazepam, triazolam, and other unspecified benzodiazepines.

14 Other non-Benzodiazepine Tranquilizers—Includes meprobamate, tranquilizers, etc

15 Barbiturates—Includes amobarbital, pentobarbital, phenobarbital, secobarbital, etc.

16 Other non-Barbiturate Sedatives or Hypnotics—Includes chloral hydrate, ethchlorvynol, glutethimide, methaqualone, sedatives/hypnotics, etc.

17 Inhalants—Includes chloroform, ether, gasoline, glue, nitrous oxide, paint thinner, etc.

18 Over-the-Counter—Includes aspirin, cough syrup, diphenhydramine

and other anti-histamines, sleep aids, and any other legally obtained, non- prescription medication.

20 Other—Includes diphenylhydantoin/phenytoin, GHB/GBL, ketamine, etc.

Guidelines: TEDS relationship between Substance Problem Codes (MDS 14 a, b and c) and

Route of Administration (MDS 15 a, b and c):

 States that do not collect detailed drug code data:

A record may not have duplicate substance problem codes (MDS 14 a, b and c) with identical routes of administration (MDS 15 a, b and c).

 States that do collect detailed drug code data:

Records may have duplicate substance problem codes and identical routes of administration IF the corresponding detailed drug codes are different or are “multiple” drug codes (see explanation under data item SuDS 1).

Other fields:

The Detailed Drug Codes (SuDS 1, 2 and 3) are used to provide a more detailed descriptions of the Substances reported in the corresponding substance problem codes (MDS 14 a, b and c). The Primary substance code corresponds to the primary detailed code, the secondary to secondary, etc. For details, refer to the Detailed Drug Codes (SuDS 1), later in this Appendix.

For guidance on which specific substances to include in the substance categories, please refer to the detailed drug categories listed for SuDS 1.

MDS 3: Co-Dependent/Collateral: If the field MDS 14 (a, b or c) is blank and

MDS 3 is ‘2’ (No), the field MDS 14 (a, b or c) will be set to Invalid (99).

If the field MDS 3 is “1” (codependent) and no substance is reported, then MDS 14 (A, B and C) should be coded “97” or “98”, depending of the State Crosswalk plan. The code “01” should not be used in this case, and the following fields should be coded 98:

MDS 15 (a-c): Usual Route of Administration, Primary, Secondary, and Tertiary

MDS 16 (a-c): Frequency of Use Primary, Secondary, and Tertiary

MDS 17 (a-c): Age of First Use, Primary, Secondary, and Tertiary

USUAL ROUTE OF ADMINISTRATION

PRIMARY MDS 15 (A)

SECONDARY MDS 15 (B)

TERTIARY MDS 15 (C)

Description: This field identifies the usual route of administration of the substance identified in corresponding Substance Problem Code.

Valid entries:	01	Oral
	02	Smoking
	03	Inhalation
	04	Injection (IV or Intramuscular)
	20	Other
	96	Not applicable—Use this code when the value in MDS 14(A) is 01 None.

FREQUENCY OF USE

PRIMARY MDS 16 (A) & DIS 22 (A) SECONDARY MDS 16 (B) & DIS 22 (B)

TERTIARY MDS 16 (C) & DIS 22 (C)

Description: Identifies the frequency of use of the substance identified in correponding

Substance Problem Code.

Valid entries:	01	No use in the past month
	02	1-3 days in the past month
	03	1-2 days in the past week
	04	3-6 days in the past week
	05	Daily

AGE OF FIRST USE

PRIMARY MDS 17 (A)

SECONDARY MDS 17 (B)

TERTIARY MDS 17 (C)

Description: For drugs other than alcohol, this field identifies the age at which the client first used the substance identified in corresponding Substance Problem Code. For alcohol, this field records the age of the first intoxication.

Valid entries:

00 Indicates a newborn with a substance dependency problem.

01 – 95 Indicates the age at first use.

_{96 Not Applicable}

Other fields: This field is cross-checked with MDS Item 8, Date of Birth to check that client age is greater than the age of first use.

TYPE OF SERVICE—KEY FIELD MDS 18

DIS 7

DIS 16

_{Description: Describes the type of service the client receives.}

Valid entries:

01 Detoxification, 24-Hour Service, Hospital Inpatient—24-hour per day medical acute care services in hospital setting for detoxification of persons with severe medical complications associated with withdrawal.

02 Detoxification, 24 Hour Service, Free-Standing Residential—24-hour per day services in non-hospital setting providing for safe withdrawal and transition to ongoing treatment.

03 Rehabilitation/Residential—Hospital (other than detoxification)—24- hour per day medical care in a hospital facility in conjunction with treatment services for alcohol and other drug abuse and dependency.

04 Rehabilitation/Residential—Short Term (30 days or fewer)—Typically, 30 days or less of non-acute care in a setting with treatment services for alcohol and other drug abuse and dependency.

05 Rehabilitation/Residential—Long Term (more than 30 days)—Typically, more than 30 days of non-acute care in a setting with treatment services for alcohol and other drug abuse and dependency; this may include transitional living arrangements such as halfway houses.

06 Ambulatory—Intensive-Outpatient—As a minimum, the client receives treatment lasting two or more hours per day for three or more days per week.

07 Ambulatory— Non-Intensive Outpatient—Ambulatory treatment services including individual, family and/or group services, and may include pharmacological therapies.

08 Ambulatory—Detoxification—Outpatient treatment services providing for safe withdrawal in an ambulatory setting (pharmacological or non- pharmacological).

_{96 Not applicable—Use this code only for co-dependents/collateral clients}

MEDICATION-ASSISTED OPIOID THERAPY MDS 19

Description: This field identifies whether the use of methadone or buprenorphine is part of the client’s treatment plan.

Valid entries:	1	Yes
	2	No

DETAILED DRUG CODE

PRIMARY SUDS 1

SECONDARY SUDS 2

TERTIARY SUDS 3

Description: This field identifies, in greater detail, the drug problem recorded in the Minimum

Data Set item “Substance Problem Code, primary.”

Guidelines:

_{ States that do not collect Detailed Drug Codes}

Use a value of Not Collected (9998) in the Detailed Drug Code fields: Primary, Secondary and Tertiary.

 States that do collect Detailed Drug Codes:

SAMHSA has established the Detailed Drug Codes, Primary, Secondary and Tertiary as a means for States to report more detailed drug information than is possible in the Substance Problem Code fields. Detailed drug codes also enable distinction between substances in instances where a client uses two (or more) drugs that are assigned the same substance problem code (MDS 14 a, b and c).

The Substance Problem Codes and the Detailed Drug Codes have been sub-divided into single and multiple drugs; i.e., drugs are said to be “single” if they cannot be further subdivided. Drugs are considered to be “multiple” if more than one drug can be placed within this category. Detailed Drugs LSD (0901) and marijuana/hashish (0401) are examples of a single drug. Aerosols (1701) and Other Benzodiazepines (1308) are examples of multiple drugs. A complete list of single and multiple drugs can be found in the following section titled “TEDS Drug Categories.”

The distinction between single and multiple drug categories is considered when two or more of a client’s substance problem codes are the same and their corresponding routes of administration are also the same.

The following standards apply to the submission of the Substance Problem Code, Route of Administration and Detailed Drug Code fields:

• For the primary, secondary and tertiary Substance Problem Code fields, a client record may not have identical drug codes in two fields with identical routes of administration AND identical SINGLE drug codes in the ASSOCIATED Detailed Drug Code fields.

• The client record may include two or more identical substance problem codes if the reported substances are further divided into different specific drug types in the associated Detailed Drug code fields.

• The client record may have duplicate instances of drugs defined as multiple in the Detailed Drug Code categories, with identical substance problem and routes of administration codes in the primary, secondary or tertiary fields.

Other fields: MDS 14 (a, b, c): Substance Problem Code, Primary, Secondary, Tertiary—If the code in the Detailed Drug Code field is not a valid subset of the corresponding code in MDS 14 (a, b, c), the current field (SuDS 1) is set to Invalid (9999).

_{Substance Problem Codes (MDS 14) are defined in the following categories:}

Single Drugs

01 None

02 Alcohol

03 Cocaine/Crack

04 Marijuana/Hashish

05 Heroin

06 Non-Prescription Methadone

08 PCP

10 Methamphetamine

Multiple Drugs

01 None

07 Other Opiates and Synthetics

09 Other Hallucinogens

11 Other Amphetamines

12 Other Stimulants

13 Benzodiazepines

14 Other Non-Benzodiazepine

Tranquilizers

15 Barbiturates

16 Other Non-Barbiturate Sedatives or

Hypnotics

17 Inhalants

18 Over the Counter

20 Other

Detailed Drug Codes (SuDS 1-3) are defined in the following categories:

[Note: The two-digit substance problem code forms the first two digits of its associated detailed drug code.]

Single Drugs

0201 Alcohol

0301 Crack

0302 Other Cocaine

0401 Marijuana/Hashish

0501 Heroin

0601 Non-Prescription Methadone

0701 Codeine

0702 Propoxyphene (Darvon)

0703 Oxycodone (Oxycontin)

0704 Meperidine (Demerol)

0705 Hydromorphone (Dilaudid)

0707 Pentazocine (Talwin)

0708 Hydrocodone (Vicodin)

0709 Tramadol (Ultram)

0710 Buprenorphine

0801 PCP or PCP Combination

0901 LSD

1001 Methamphetamine/Speed

1101 Amphetamine

1103 Methylenedioxymethamphetamine

(MDMA, Ecstasy)

1202 Methylphenidate (Ritalin)

1301 Alprazolam (Xanax)

1302 Chlordiazepoxide (Librium)

1303 Clorazepate (Tranxene)

1304 Diazepam (Valium)

1305 Flurazepam (Dalmane)

1306 Lorazepam (Ativan)

1307 Triazolam (Halcion)

1309 Flunitrazepam (Rohypnol)

1310 Clonazepam (Klonopin, Rivotril)

1501 Phenobarbital

1502 Secobarbital/Amobarbital (Tuinal)

1503 Secobarbital (Seconal)

1601 Ethchlorvynol (Placidyl)

1602 Glutethimide (Doriden)

1603 Methaqualone

1801 Diphenhydramine

2001 Diphenylhydantoin/Phenytoin (Dilantin)

2003 GHB/GBL

2004 Ketamine (Special K)

Other or Unspecified Drugs

0706 Other Opiates or Synthetics (includes bu- torphanol (Stadol), morphine (MSContin), and other narcotic analgesics)

0902 Other Hallucinogens

1109 Other Amphetamines

1201 Other Stimulants

1308 Other Benzodiazepines

1403 Other Tranquilizers

1509 Other Barbiturate Sedatives

1604 Other Non-Barbiturate Sedatives

1605 Other Sedatives

1701 Aerosols

1702 Nitrites

1703 Other Inhalants

1704 Solvents

1705 Anesthetics

1809 Other Over-the-Counter (includes ephed- rine, Dextromethorphan (DXM))

2002 Other Drugs (includes carisoprodol

(Soma))

9996 Not Applicable. Use this code when the value in MDS 14 (A, B or C) is 01 (None)

DSM DIAGNOSIS SUDS 4

Description: The diagnosis of the substance abuse problem from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. DSM IV is preferred, but use of the third edition, or ICD codes is permissible. If the DSM IV is not used, the State must specify the coding system in State crosswalk.

Valid entries: (XXX.xx) (XXX.x- ) (XXX . - - ) (XXX - - - ) where – represents a blank.

Guidelines: Valid entries generally will have 3 characters and a decimal point followed by 1 or 2 characters. If a valid code has fewer than 5 characters and a decimal, the code should be left justified so that all remaining characters on the right are blank. While a three-character code with no decimal or following digits will be accepted, virtually all substance abuse diagnosis codes have at least one digit to the right of the decimal. States should strive to obtain complete coding with sufficient digits to accurately code the diagnosis.

PSYCHIATRIC PROBLEM IN ADDITION TO

ALCOHOL OR DRUG PROBLEM SUDS 5

Description: Identifies whether the client has a psychiatric problem in addition to his or her alcohol or drug use problem.

Valid entries: 1 Yes

2 No

PREGNANT AT TIME OF ADMISSION SUDS 6

_{Description: Specifies whether the client was pregnant at the time of admission}

Valid entries:

1 Yes

2 No

_{6 Not Applicable - Use this code for Male Clients.}

Other fields: MDS 9: Sex—If the value of the current field is 1 (Yes) and the value in MDS 9 is not “2” (Female), this field is set to 6 (Not applicable).

VETERAN STATUS SUDS 7

Description: Identifies whether the client has served in the uniformed services (Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Service Commissioned Corps, Coast and Geodetic Survey, etc).

Valid entries:

1 Yes

_{2 No}

Guidelines: A Veteran is a person 16 years or over who has served (even for a short time), but is not now serving, on active duty in the US Army, Navy Air Force, Marine Corps, Coast Guard, or Commissioned Corps of the US Public Health Service or National Oceanic and Atmospheric Administration, or who served as a Merchant Marine seaman during World War II. Persons who served in the National Guard or military Reserves are classified as veterans only if they were ever called or ordered to active duty, not counting the 4-6 months for initial training or yearly summer camps.

LIVING ARRANGEMENTS—NOM SUDS 8

DIS 23

Description: Specifies whether the client is homeless, living with parents, in a supervised setting, or living on his or her own.

Valid entries:

01 Homeless—Clients with no fixed address; includes shelters.

02 Dependent living— Clients living in a supervised setting such as a residential institution, halfway house or group home, and children (under age 18) living with parents, relatives, or guardians or in foster care.

03 Independent Living – Clients living alone or with others without supervision.

Includes adult children (age 18 or over) living with parents.

SOURCE OF INCOME/SUPPORT SUDS 9

Description: Identifies the client’s principal source of financial support. For children under 18, this field indicates the parent’s primary source of income/support.

Valid entries:	01	Wages/Salary
	02	Public Assistance
	03	Retirement/Pension
	04	Disability
	20	Other
	21	None

HEALTH INSURANCE SUDS 10

Description: Specifies the client’s health insurance (if any). The insurance may or may not cover alcohol or drug treatment.

Valid entries:

01 Private Insurance (other than Blue Cross/Blue Shield or an HMO)

02 Blue Cross/Blue Shield

03 Medicare

04 Medicaid

06 Health Maintenance Organization (HMO)

20 Other (e.g., TRICARE)

_{21 None}

Guidelines: If a State collects Medicare and Medicaid as one category, clients with that health insurance should be coded Unknown 97.

EXPECTED/ACTUAL PRIMARY SOURCE OF PAYMENT SUDS 11

_{Description: Identifies the primary source of payment for this Treatment Episode.}

Valid entries:	01	Self-Pay
	02	Blue Cross/Blue Shield
	03	Medicare
	04	Medicaid
	05	Other Government Payments
	06	Worker’s Compensation
	07	Other Health Insurance Companies
	08	No Charge (free, charity, special research or teaching)
	09	Other

Guidelines: If a State collects Medicare and Medicaid as one category, clients with that Expected Primary Source of Payment should be coded Unknown 97. States operating under a split payment fee arrangement between multiple payment sources are to default to the payment source with the largest percentage. When the payment percentages are equal, the State can select either source.

DETAILED NOT IN LABOR FORCE—NOM SUDS 12

DIS 25

Description: This field gives more detailed information about those clients who are coded as

_{“not in the labor force” in MDS 13, Employment Status.}

Valid entries:	01	Homemaker
	02	Student
	03	Retired
	04	Disabled
	05	Inmate of Institution (Prison or institution that keeps a person, otherwise able, from entering the labor force.)
	06	Other

96 Not Applicable - Use this code if Employment Status (MDS 13/DIS 25) is coded 01, 02 or 03.

Guidelines: This field is to be used only when Employment Status (MDS 13/DIS 25) is coded

04 “Not in Labor Force.” For all other entries in Employment Status, this field should be coded 96 (Not Applicable).

DETAILED CRIMINAL JUSTICE REFERRAL SUDS 13

Description: This field gives more detailed information about those clients who are coded as

_{“Criminal justice referral” in MDS 7, Principal Source of Referral.}

Valid entries:	01	State/Federal Court
	02	Other Court (not State or federal)
	03	Probation/Parole
	04	Other Recognized Legal Entity (E.G. local law enforcement agency, corrections agency, youth services, review board/agency)
	05	Diversionary Program (e.g., TASC)
	06	Prison
	07	DUI/DWI
	08	Other

Guidelines: This field is to be used only when Principal Source of Referral (MDS 7) is coded

07 “Criminal Justice Referral.” For all other entries in Principal Source of Referral, this field should be coded 96 (Not Applicable).

MARITAL STATUS SUDS 14

Description: Describes the client’s marital status. The following categories are compatible with the U.S. Census.

Valid entries:

01 Never Married—Includes clients whose only marriage was annulled.

02 Now Married—Includes those living together as married.

03 Separated—Includes those separated legally or otherwise absent from spouse because of marital discord.

04 Divorced

05 Widowed

DAYS WAITING TO ENTER TREATMENT SUDS 15

Description: Indicates the number of days from the first contact or request for service until the client was admitted and the first clinical service was provided.

Valid entries: 000-996 Number of days waiting (ex. 1 day = 001, 10 days = 010)

Guidelines: This item is intended to capture the number of days the client must wait to begin treatment because of program capacity, treatment availability, admissions requirements, or other program requirements. It should not include time delays caused by client unavailability or client failure to meet any requirement or obligation.

ARRESTS IN 30 DAYS PRIOR TO SUDS 16

ADMISSION/DISCHARGE—NOM DIS 26

Description: The number of arrests in the 30 days preceding the date of admission to treatment services.

Valid entries: 00-96 Number of arrests

Guidelines: This item is intended to capture the number of times the client was arrested for any cause during the 30 days preceding the date of admission to treatment. Any formal arrest is to be counted regardless of whether incarceration or conviction resulted and regardless of the status of the arrest proceedings at the time of admission.

FREQUENCY OF ATTENDANCE AT SELF-HELP SUDS 17
PROGRAMS IN 30 DAYS PRIOR TO DIS 27

ADMISSION/DISCHARGE—NOM

Description: The number of times the client has attended a self-help program in the 30 days preceding the date of admission to treatment services. Includes attendance at AA, NA, and other self-help/mutual support groups focused on recovery from substance abuse and dependence.

Valid entries:	01	No attendance in the past month
	02	1-3 times in past month (less than once per week)
	03	4-7 times in past month (about once per week)
	04	8-15 times in past month (2 or 3 times per week)
	05:	16-30 times in the past month (4 or more times per week)
	06:	Some attendance in the past month, but frequency unknown
	97:	Unknown
	98:	Not Collected

Unknown (97) Use this code if the State collects these data, but for some reason this record does not reflect an acceptable value.
Not Collected (98) Use this code if the State does not collect these data for submission to TEDS.

Guidelines: Use Code 06 (frequency unknown) only if it is known that the client attended a self-help program during the month prior to admission, but there is insufficient information to record one of the specific frequency categories. Use Code 97 (unknown) when it is not known whether the client attended a self-help program during the month prior to admission.

Use number of times attended self-help programs, not number of days, i.e., if a client attends self-help programs multiple times per day, let the number of times rather than the approximate times per week determine the response category. If the number exceeds 30 times in the prior 30 days, use the response category 16-30 times.

DATE OF LAST CONTACT DIS 8

Description: The day when the client is last seen for a treatment. The date may be the same date as the date of discharge. In the event of a change of service or provider within an episode of treatment, it is the date the client transferred to another service or provider.

Valid Entries: MMDDYYYY

The record must have a valid date. MM must be 01 - 12 and DD must be 01 - 31. YYYY must be 2001 or later.

DATE OF DISCHARGE - (KEY FIELD) DIS 9

Description: Specifies the month, day and year when the client was formally discharged from the treatment facility or service. The date may be the same as date of last contact. In the event of a change of service or provider within an episode of treatment, it is the date the service terminated or the date the treatment ended at a particular provider.

Valid Entries: MMDDYYYY

The record must have a valid date. MM must be 01 - 12 and DD must be 01 - 31. YYYY must be 2001 or later.

REASON FOR DISCHARGE, TRANSFER,

OR DISCONTINUANCE OF TREATMENT DIS 10

Description: Indicates the outcome of treatment or the reason for transfer or discontinuance of treatment

Valid Entries:

01 Treatment completed—All parts of the treatment plan or program were completed.

02 Left against professional advice (includes “dropped out” of treatment)— Client chose not to complete treatment program, with or without specific advice to continue treatment. Includes clients who “drop out” of treatment for unknown reason and clients who have not received treatment for some time and are discharged for “administrative” reasons.

03 Terminated by facility—Treatment terminated by action of facility, generally because of client non-compliance or violation of rules, laws or procedures (not because client dropped out of treatment, client incarcerated or other client motivated reason).

04 Transferred to another substance abuse treatment program or facility.

This code is to be used for all clients who have a change of service or provider within an episode of treatment, except when it is known that the client did not report to the next program.

14 Transferred to another substance abuse treatment program or facility, but did not report. This code is to be used for all clients who have a change of service or provider within an episode of treatment, but who are known not to have reported to the next program.

05 Incarcerated—This code is to be used for all clients whose course of treatment is terminated because the client has been incarcerated (includes jail, prison, house confinement).

06 Death

07 Other—Includes client change of residence, illness, hospitalization, or other reason somewhat out of client’s control

08 Unknown—Client status at discharge in not known because, e.g., discharge record is lost or incomplete. DO NOT USE THIS CATEGORY FOR CLIENTS WHO DROP OUT OF TREATMENT, WHETHER REASON FOR DROP- OUT IS KNOWN OR UNKNOWN.